<form action="<?=PHP_SELF?>" method="post">
	<input type="hidden" name="regiones[id_region]" value="<?=empty($id_region)?0:$id_region?>"/>
	<table style="width:100%">
		<tr>
			<th colspan="3"><input class="openmodalbox"	type="submit" value="Guardar Datos" /></th>
		</tr>
		<tr>
			<td>Nombre de Region</td>
			<td><input type="text" name="regiones[region_name]" value="<?=empty($region_name)?null:$region_name;?>" placeholder='nombre de region' required="required"/></td>
		</tr>
        <tr>
		<td>provincias </td>
			<td><input type="text" name="regiones[prov]" value="<?=empty($prov)?null:$prov;?>" placeholder='Provincia nas' required="required"/></td>
		</tr>
		<tr>
			<td colspan="3">
			<fieldset style="margin:0px; padding:2px;">
				<legend>Otros </legend>
				<textarea name="regiones[otro]" id="" cols="30" rows="5" style="width:100%"><?=empty($otro)?null:$otro?></textarea>
			</fieldset>
			</td>
		</tr>
		<tr>
			<th colspan="2"><input class="openmodalbox"	type="submit" value="Guardar Datos" /></th>
		</tr>
	</table>
</form>